GERD Symptom Questionnaire
Please complete this questionnaire to help assess your symptoms related to Gastroesophageal Reflux Disease (GERD).
Full Name
*
First Name
Last Name
Age
*
Email Address
example@example.com
How often have you experienced the following symptoms in the past week?
*
Rows
Never
Rarely
Sometimes
Often
Always
Heartburn (burning feeling behind the breastbone)
1
2
3
4
5
Regurgitation (acid or food coming back up)
6
7
8
9
10
Chest pain unrelated to heart
11
12
13
14
15
Difficulty swallowing
16
17
18
19
20
Sore throat or hoarseness
21
22
23
24
25
Coughing or wheezing
26
27
28
29
30
How severe are your GERD symptoms overall?
*
Not severe
1
2
3
4
5
6
7
8
9
Extremely severe
10
1 is Not severe, 10 is Extremely severe
When do your symptoms usually occur?
*
After eating
At night/while lying down
During exercise
Random times
Other
Do you currently take any medication or treatment for your symptoms?
*
Yes
No
If yes, please list the medications or treatments you use.
How much do GERD symptoms affect your daily life?
*
Not at all
1
2
3
4
5
6
7
8
9
Severely
10
1 is Not at all, 10 is Severely
Have you made any lifestyle changes to manage your symptoms?
Diet modification
Weight loss
Elevating head while sleeping
Avoiding late meals
Quitting smoking
Other
Is there a family history of GERD or similar digestive problems?
Yes
No
Not sure
Additional comments or details about your symptoms (optional)
Submit
Should be Empty: